Attitudes have always represented a hot topic for researchers, due to their direct influence on a range of behaviours. More specifically, stigmatising attitudes towards people with mental illness have been keenly investigated over recent years because of their potential to bring about severe negative outcomes for people living with mental health conditions.

Some studies show that these attitudes change over time, but the change is not the same for different types of mental illness. For example, recent research showed that attitudes towards people with schizophrenia worsen with the passing of time, while attitudes towards people with depression remain stable (Angermeyer et al., 2013).

Taking into consideration the global phenomena of the aging population across all societies, we must pay attention to the fact that the attitudes of older individuals are becoming more and more influential. The level of stigmatising attitudes towards people with mental illness will increase as a direct consequence of the increased proportion of older people. Also, studies show that high levels of stigma are linked to high suicide rates and low help-seeking behaviours (Reynders et al., 2014), which would clearly increase the need of psychological interventions in old age.

Given that most studies investigating this phenomena are cross-sectional, it has not been clear if the correlations they presented, between age and negative attitudes towards people with mental illness indicate a true age effect. However, a recent German study published in Acta Psychiatrica Scandinavica (Schomerus et al., 2015) set out to examine whether stigmatising attitudes towards people with mental illness (depression and schizophrenia) increase with age, and to what extent they follow a cohort pattern.

This age-period-cohort study looked at how our attitudes towards mental illness change as we age.

Methods

The data was derived from three methodologically identical population-based cross-sectional surveys conducted on a randomly selected sample of the German population. The surveys were conducted in 1990, 2001 and 2011. The combined final study sample consisted of 7,835 participants.

In all three surveys participants had to response to the same interview, conducted face-to-face using pencil and paper. First, they were presented with a vignette of a diagnostically unlabelled case history describing a person who was suffering from schizophrenia or a person who had major depression and then they were asked to respond to a few questions. The symptoms described in the vignette fulfilled the criteria of DSM-III-R for both disorders and were also validated by five experts in psychopathology.

Out of the 7,835 participants, 3,925 received the vignette depicting a person suffering from schizophrenia, while 3,910 received the vignette describing a person with major depression. Researchers used a social distance scale which measures the willingness to engage in different activities with a person with mental illness.

Results

Given the fact that the sex of the individuals presented in the vignette varied at random in the surveys conducted in 1990 and 2011, but not in 2001 (only men were presented), this study reveals only results based on responses elicited with the male vignette.

Results from the study show that the linear model had a significant age effect for both disorders (depression and schizophrenia). The scored increased by 0.032 per year for schizophrenia and by 0.031 per year for depression. Over the life-span this cumulates into an increased social distance of 2.4 for schizophrenia and 2.3 for depression. In the non-linear models, the non-linear relation between social distance and age was rejected by the Wald-tests.

Regarding the cohort effects, linear models showed a cohort effect in depression but not in schizophrenia, with persons who were born later exhibiting lower social distance towards individuals suffering from depression. In the non-linear models, the Wald test confirmed a non-linear relationship between birth-cohort and social distance in depression, but not in schizophrenia. Also, the non-linear cohort effects showed a relatively stable decrease by 1.92 points in social distance from birth cohort 1925 to birth cohort 1970, followed by an increase of 0.57 points to 14.67 in birth cohort 1990.

There was a significant period effect for schizophrenia, meaning that people from the more recent surveys had higher social distance scores than those from an earlier survey for every time period. For depression, there was an increase of social distance of 0.6 significant only when calculating the difference between 1990 and 2011.

The study found that negative attitudes towards mental illness increase with growing age in all birth cohorts.

Conclusions

The results of the study show a consistent age effect in depression and schizophrenia, with an increased social distance towards individuals with mental illness as time passes. Cohort effects differ between disorders only for depression. Attitudes towards a person with depression became more tolerant in younger cohorts until the 1970 cohort, only to deteriorate again after this point.

Nonetheless, I consider that, although the authors conducted a very important study their focus on only three variables (age, cohort and period) might diminish the relevance of their results. For example, socio-demographic variables can often add valuable information regarding the results and their meanings.

Another aspect of concern regarding this study is represented by the way the data were collected. Stating what you think about individuals with mental illness, to a complete stranger, while he/she is taking notes might be quite a challenge for many people. Social desirability might have different effects on the results.

Another limitation of the study (also presented by the authors) relates to the use of the vignette depicting only males, which might have increased the social distance towards individuals with mental disorders due to the level of threatening characteristics perceived by others.

Still, given the significant results for age effect for both disorders, we should turn our attention to more targeted anti-stigma interventions for different age groups, rather than population-wide interventions.

Should we consider targeting anti-stigma programmes specifically at older people?

Raluca is a PhD Candidate at Babes-Bolyai University, Cluj Napoca. Her main research interests are centered on attitudes towards aging the aging process, and aging processes aimed at improving the welfare of the elderly. She holds a master’s degree in Clinical Psychology and is a board certified clinical psychologist who aims to reduce the psychological distress and enhance/promote the psychological well-being of individuals.

Do you think the study would benefit from the use of a “control vignette” where no symptoms of mental illness are described? Otherwise how do we know the increasing social distance with age isn’t due to general social isolation that the elderly can be at risk of rather than an stigmatising attitudes on their part?

We are currently developing an online Relatives’ Education and coping toolkit (REACT) for people supporting someone with psychosis / bipolar disorder. We are really keen to hear from relatives who would be willing to attend a meeting at Lancaster University to discuss how best to design and develop this site to best meet the needs of relatives

[…] Although intended for the “general public”, it would be useful to know whether there are differences in impact depending on the particular groups involved, particularly whether it is more or less likely to be effective depending on how much mental health knowledge the person already has. It’s quite likely however that this level of detail wouldn’t have been available in the papers included, but is perhaps something to consider for future research. This knowledge may help us tailor training to specific populations, e.g. older people, who are more likely to have negative attitudes to mental illness. […]